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FOR FFICE USE: r_ ------------------....... ___.-.- _------------------ ---- APPLICATION 'PO ?'A 'R NITATION PERMIT Permit No. /fl--.GG ��.. . P. 2 ------------_A---------- ---------------- (Complete in Duplicate) 7 Date Issued ------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No 549. r JOB ADDRESS AND LO AT/PN--- ,.�% ....-= - ------�----------------- Owner's Name ------------- --- -- ---------- Phone ` I r— Address $ ------------- ------ ,• ----------------.._...------------------------------------------------•-- s Contractor's Name________________ ,: _ ------•--------------------------- -----------------•-•---------•-------------------._..__ Phone......../V................... Installation will serve: Residence ] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El Q Number of living units: ___ ___ Number of bedrooms _j__ Number of baths __ _._ Lot size40__X.- ---- --------------------- Wafer Water Supply: Public system 1K Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ lay E] AdobelIQ Hardpan ❑ Previous Application Made: (If yes,date____________________) No New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---, stance from foundation____f __ __.Material_ -att�4__ __ ( No. of compartments-____.__ Size____„!'__�4 _Liquid depth__________________________Capacity__ i�Q#_.________ -- • - - j Disposal Field: Distance from nearest well...d11&"__4.bistance from foundation_____ Distance to nearest lot line_ -_ r ilf -5------------ IV Number of lines-----______- _ ____-__ __ Length of each line------ __Q_-----------Width of trench____ :- ----------- Type of filter matDepth__Depth of filter material__- _*#-------- length___^R--- --------- Seepage Pit: Distance to nearest well___-------------------Distance from foundation--------------------Distance to nearest lot line__.___-____.___ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-----------.--------------------- X Cesspool: Distance from nearest well-------_---------Distance from foundation------------------..Lining material------------------------------------- r F-1 Size: Diameter------------------------- -----------Depth.-------------------- -----------------------------Liquid Capacity-. ------------------------gals. Privy: Distance from nearest well -----------------------------------------------Distance from nearest building_____________--_-_---__________________- ❑ Distance to nearest lot line--- --- ---------------- Remodeling and/or repairing (describe):----------------------------------------------------------------------------- ------------------•-------------...----------------------------------------- --------------•--------------•----------------------•--•------------------------------------------------------ ----------------------•-----------------------------------------------------•------------------- -------------- ¢ ------------------ ------------------------------------------•--------•-------------------------------------------------------------------------------------------------------------------..---------------------------------9 -----------------------------------------------------------------------------------------•--•----------------------------------------------•----------------------------------------•------------------------------------- I hereby certify that I have prepared this application qpd that the work will be done in accordance with San Joaquin County ordinances. State law and r les and regOations of the Sin Joaquin Local Health District. (Signed)--- - --- -------- ------ ---.---------------------------- --(Owner and/or Contractor) -- --- r' By-------------------------------------------------------------------------------------- --------------------------------------------(Title)------- ----------- -------•--- ----------- --- -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------Cl ------------------------------------------------------------------------- DATE--------- —----------------------- REVIEWEDBY----------------------------------- ----------------------------------------------------------------------------------------- DATE-------- ---------------- BUILDhGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------- Alterations and/or recommendations--------------- -- -------------------------------------------------------•----•--------------•------------------------------------------•------------------- -•-------------------------------------------------------------------- ------------------------------------------------------------------------------------------•------------- ---1----------------------------------------- FINAL INSPECTION BY-------------- f_---------------- --------------------- Date--- -- ----------------- --------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocktonr California Lodi,California .. Manteca,California Tracy,California r A . ^ E5 9 REVISED 5-59 3M 3-'63 F.P.CC. ^